[COMPANY] COVID-19 Questionnaire

Safety is a core value of [COMPANY] and as such the health and well-being of our employees, visitors and contractors is paramount.

Due to the unprecedented concern for the COVID-19 (Coronavirus) [COMPANY] is requesting all visitors and contractors fill out this voluntary survey before being granted access to any of our facilities.

Name: ___________________________________________

Company: _______________________________________

Date: ____________________________________________

1. Have you been out of the country in the past three weeks? If yes, which countries andairports did you travel through?

2. Have you experienced any of the following symptoms in the past three weeks? If yes,please check associated box.

a. Fever of 100.4° or higherb. Coughc. Shortness of Breathd. Persistent Pain or Pressure in the chest

3. Have you been in close contact with anyone showing any of these symptoms oranyone who has been diagnosed with COVID-19 (Coronavirus)?

If you have any questions or concerns, please contact:

Company Contact Company NameCompany Contact TitlePhone NumberEmail

DISCLAIMER OF LIABILITY: This document was prepared by the Society of Chemical Manufacturers and Affiliates (SOCMA) and is disseminated for informational and educational purposes only. This information is not intended as legal guidance and does not create any legal relationship or responsibility between SOCMA and user. Nothing contained herein is intended to revoke or change the requirements or specifications of individual manufacturers or local, state and federal officials that have jurisdiction in your area. The user is responsible for assuring compliance with all applicable laws and regulations.